Post-transplant lymphoproliferative disorder as a cause of oesophageal ulceration and stricture: case report and literature review.

Post-transplant lymphoproliferative disorder (PTLD) of the oesophagus is a rare complication of solid organ transplant that requires a high index of suspicion to diagnose. A literature review conducted on Ovid Medline database retrieved 24 articles, among which five previous cases of oesophageal PTLD were identified. Development of oesophageal strictures related to PTLD has not been reported in the literature. We report a case of oesophageal PTLD following lung transplant, presenting with extensive, circumferential ulceration in the oesophagus. PTLD was successfully treated with chemotherapy but subsequently, this patient developed a severe oesophageal stricture at the site of her PTLD. She presented with an episode of food bolus impaction requiring endoscopic retrieval. In the following years, our patient required multiple endoscopic dilatations of this PTLD-related oesophageal stricture.

Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists.

OBJECTIVE: To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients. METHODS: Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient. RESULTS: Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners. CONCLUSION: ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

Randomized controlled trial of virtual reality simulator training: transfer to live patients.

BACKGROUND: New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients. METHODS: A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments. RESULTS: In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance. CONCLUSIONS: Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement.

Antioxidant vitamin supplementation in Crohn's disease decreases oxidative stress. a randomized controlled trial.

OBJECTIVE: We showed previously that patients with Crohn's disease (CD) had increased oxidative stress and lower antioxidant vitamins compared with healthy controls. This is despite inactive or mildly active disease and maintenance therapy. The aim of this study was to evaluate in these patients the effects of antioxidant vitamin supplementation on oxidative stress. METHODS: This is a randomized controlled trial where stable but oxidatively stressed CD subjects (n = 57) were supplemented with vitamins E (800 IU) and C (1000 mg) or their placebo for 4 wk. Oxidative stress measured by breath pentane and ethane output, plasma lipid peroxides, and F2-isoprostane was assessed at baseline and at 4 wk. Disease activity was also monitored by measuring CD activity index and plasma orosomucoid. RESULTS: During supplementation, plasma vitamin C and alpha-tocopherol increased and all indices of oxidative stress decreased significantly. Disease activity remained stable. CONCLUSIONS: In this population, vitamin E and C supplementation resulted in a significant reduction in oxidative stress. This suggests that patients with inactive or mildly active CD can be oxidatively stressed and have increased requirement in antioxidant vitamins.